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DIABETES EDUCATION PROGRAM Phone - (705)325-7611 SOLDIERS’ MEMORIAL HOSPITAL Fax Type of diabetes: MEDS Oral hypoglycemic agent: Date initiated: ADULT REFERRAL FORM - (705)327-9162 Name ___________________________________ Addresss _________________________________ City & Postal Code _________________________ Health Card # _____________________________ DIAGNOSIS III-10 DOB (D/M/Y) _____________________________ Telephone (Home) __________________________ Telephone (Work) __________________________ Next Of Kin _______________________________ Length of time since diagnosis: Criteria used for diagnosis: ___________ (See Over) Insulin: Date initiated: Other: PAST MEDICAL HISTORY Hypertension ___ Renal Disease ___ Retinopathy ___ Hypothyroid Neuropathy Obesity ___ CHF ___ ___ MI ___ ___ CVA ___ PSYCHOSOCIAL RISK FACTORS Depression ___ Alcoholism ___ Chronic Anxiety ___ Illiteracy ___ LEVEL OF MOTIVATION High Average Low Nil REQUIRED LAB WORK (Please forward copy of lab work to DEC.) ___ ___ ___ ___ Other: Other: Comments: Date _________ Result _____ Glycated Hb _________ _________ _________ _________ _________ _____ _____ _____ _____ _____ Urinalysis(Macroprotein) Microalbuminuria Albumin/Creatinine Serum Creatinine TSH Date _______ _______ Result _____ FBG _____ RBG Date Result _____ _____ FBG _____ _____ RBG Date ________ ________ ________ ________ ________ Result _____ Total Cholesterol _____ LDL _____ HDL _____ Chol/HDL _____ Triglycerides Please indicate where the follow-up evaluation of the above tests will be requested: Diabetes Centre _____ Physician’s Office _____ (Please note on lab requisitions that diabetes-related results be copied to the DEC.) Do you want your patient to have a blood glucose monitor? Yes___ No___ Patient already owns one___ It is often necessary to leave messages to book, confirm or change appointments. Please indicate below which are acceptable to the patient: Answering Machine: Yes□ No□ Family Members: Yes□ No□ Friends: Yes□ No□ Co-Workers: Yes□ No□ Please note that a referral to the Diabetes Education Centre may include attendance at Education Modules that involves other health care professionals such as physicians, pharmacists, chiropodists, physiotherapists and occupational therapists. Comments: ________________________________________________________________________________ __________________________________________________________________________________________ Physician’s Name ______________________ Date: _______________ Referred By: _______________ Physician’s Signature ___________________ January 2007 PLEASE TURN OVER Diagnosis of Diabetes Mellitus A confirmatory laboratory glucose test (on FPG, casual PG or a 2 hour PG in a 75-g OGTT) must be done in all cases on another day in the absence of unequivocal hyperglycemia accompanied by acute metabolic decompensation. FPG (Fasting Plasma Glucose) >/= 7.0 mmol/L Fasting = no caloric intake for at least 8 hours. or Casual PG (Plasma Glucose) >/= 11.1 mmol/L + symptoms of diabetes Casual = any time of the day, without regard to the interval since the last meal. Classic symptoms of diabetes = polyuria, polydipsia and unexplained weight loss. or 2 Hour PG in a 75-g OGTT (Oral Glucose Tolerance Test) >/= 11.1 mmol/L Plasma Glucose (PG) Levels for Diagnosis of IFG, IGT and Diabetes IFG IFG (isolated) IGT (isolated) IFG and IGT Diabetes - Impaired Fasting Glucose Impaired Fasting Glucose Impaired Glucose Tolerance Impaired Fasting Glucose Impaired Glucose Tolerance FPG (mmol/L) 2hPG in a 75-g OGTT (mmol/L) 6.1 – 6.9 6.1 – 6.9 < 6.1 6.1 – 6.9 and and and N/A < 7.8 7.8 – 11.0 7.8 – 11.0 >/= 7.0 or >/= 11.1 Gestational Diabetes Mellitus (GDM) All pregnant women should be screened for GDM between 24 and 28 weeks’ gestation. Women with multiple risk factors should be screened during the first trimester and, if negative, should be reassessed during subsequent trimesters. Plasma glucose (PG) should be measured 1 hour after a 50-g glucose load. 50-g Glucose Screening Test 1 hour PG * 7.8 to 10.2 mmol/L 75-g OGTT * >/= 10.3 mmol = GDM 75-g (OGTT) Oral Glucose Tolerance Test FPG * >/= 5.3 mmol/L 1 hour PG * >/= 10.6 mmol/L 2 hour PG * >/= 8.9 mmol/L - A diagnosis of GDM requires 2 abnormal values among the 3 measurements. - If only one value is met or exceeded, the diagnosis is Impaired Glucose Tolerance of Pregnancy (IGT of pregnancy). References: 2003 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Canadian Journal of Diabetes 2003: 27 (Supplement 2).